complaint·November 19, 2025

*AMENDED* LPA noted that the pharmacy receipt photographed by F1 noted two boxes of medication in question at a quantity of 50 pills per each box. At the top of the photo there was a highlighted note "1 box qty.50-to (Administrator)" and "1 box qty.50- (F1) Kept" On 11/18/2025 LPA conducted a phone interview with F1 who stated that they provided the facility with one box of 50 and kept one box of 50 of the medication in question; as noted on the photograph provided by F1. On 11/19/2025 LPA Jeffries conducted a cursory medication audit of medication in question to the allegation to this complaint. LPA Jeffries noted that the Medication Administration Record (MAR) Resident 1 (R1) for November 2025; MAR shows 18 entries were noted for the medication in question to the allegation. LPA observed the facility Centrally Stored Medication Record (CSMR) for R1 that noted entry of "18 Pills" and "Plus 50" were entered into the CSMR. LPA noted that there were a total of 50 pills counted during medication audit, in addition to the 18 MAR entries equalling the total on the CSMR, showing that the correct pill count for the medication in question was noted from MAR, CSMR and physical medication audit by LPA. Based on interview with F1, MAR, CSMR, and physical medication audit by LPA there is not enough evidence to support the allegation of "Staff mismanaged resident's medication." and is unsubstantiated at this time. Exit interview, report read, and report provided.